Behavior Support Plan Good Day Plan DHS 4588GDP



|[pic] | |

|Office of Developmental Disabilities | |

|Stabilization and Crisis Unit | |

| |Good Day Plan |

| | |

|Client name: |      |Date of plan: |      |

| |

|Revised: |

|      |

|Revised: |

|      |

|Revised: |

|      |

|Revised: |

|      |

|Revised: |

|      |

|Revised: |

|      |

| |

| |

|I. Client profile |

| |Individuals interviewed and/or consulted for the Assessment Plan | |Date interview process is|

| | | |started: |

| |      | |      |

| | | | |

| | | |Use this date on RTRs, |

| | | |ect. |

| | | | |

| | |

| |Client identifying information: |

| |      |

| | |

| |Psychosocial history: |

| |      |

| |Review of dangerous behaviors: |

| |      |

| Below add sections and add the name and specific behaviors as needed. |

| |Name of behavior 1. |      |

| | |Frequency: |      |

|Context: |      |

| | |Duration: |      |

|Intensity/severity: |      |

| | |

| Interferes with community or social participation | Threatens the safety of others or infringes on the rights of others |

| Interferes with skill acquisition or other activities | Is a risk to the health or safety of self |

| |Name of behavior 2. |      |

| | |Frequency: |      |

|Context: |      |

| | |Duration: |      |

|Intensity/severity: |      |

| | |

| Interferes with community or social participation | Threatens the safety of others or infringes on the rights of others |

| Interferes with skill acquisition or other activities | Is a risk to the health or safety of self |

| |Contributing medical conditions that may have an impact on an individual’s behavior(s): |

| |      |

|. |How the mental health diagnosis manifests in the individual: |

| |      |

| |

|II. Client needs, preferences, relationships |

| | |

| |Needs: |

| |      |

| |Preferences: |

| |      |

| |      |

| |Relationships: |

| |      |

| |Expressive communication: |

| |      |

| |Receptive communication: |

| |      |

| |Communication in distress: |

| |      |

|III. Behavior definitions |

| | |

| | |

| |Behaviors to increase: | |

| | |

| |Behavior to increase 1. |      Define:       |

| |Data collection: |      |

| | | |

| |Behavior to increase 2. |      Define:       |

| |Data collection: |      |

| |Behaviors to decrease: |Some have similar or the same “Triggers”: Used to support client in learning how to express his concerns in |

| | |an appropriate manner. |

| | |

| | Elaborate in first reference similar “Triggers” and “Precursors.” Check box if different and explain. |

| |Setting events: |

| |      |

| |Triggers: |

| |      |

| |Precursors: |

| |      |

| |Name of behavior 1. |      |

| |Definition: |      |

| | | Trigger same first reference | Precursor same first reference |Setting event same first reference |

| | |Trigger different, explain: |Precursor different, explain: |Setting event different, explain: |

| | |      |      |      |

| | | |

| | |Data collection: |      |

| | |Alteration criteria: |      |

| |Name of behavior 2. |      |

| |Definition: |      |

| | | Trigger same first reference | Precursor same first reference |Setting event same first reference |

| | |Trigger different, explain: |Precursor different, explain: |Setting event different, explain: |

| | |      |      |      |

| | | |

| | |Data collection: |      |

| | |Alteration criteria: |      |

|IV. Behavior functions |

| |Behavior chains / response classes: |

| |      |

| |Function of behavior(s): |

| |      |

| |Functional alternatives to behavior(s): |

| |      |

| |Incentive plan: Not applicable       |

|V. Proactive strategies |

| | |

| |Supervision levels (general): |

| |Check if applicable |

| |Awake: Bedroom |

| |Asleep: Bedroom |

| |Bathroom |

| |Kitchen |

| |Living / dining room |

| |Laundry room |

| |Yard |

| |Stores |

| |Parks |

| |Restaurants |

| |Crowded community events (fairs) |

| | |

| |Not allowed in room |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |3 – feet |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |10 – feet |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |In the same room |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Visual contact at all times |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |15 – minute visual checks |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |30 – minute visual checks |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Hourly visual checks |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Check visual every 2 – hours |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Other:       |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Supervision levels (other): |

| |Check if applicable |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| |Other:       |

| | |

| |Not allowed in room |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |3 – feet |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |10 – feet |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |In the same room |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Visual contact at all times |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |15 – minute visual checks |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |30 – minute visual checks |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Hourly visual checks |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Check visual every 2 – hours |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |Other:       |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| | |

| |General staff interaction guidelines: |

| |      |

| | |

| |Community outing guidelines: |

| |      |

| | |

|VI. Reactive strategies |

| | |

| |General: |

| |      |

| |Community: |

| |      |

|VII. Crisis strategies – BSP essential components |

| | |

| |General: |

| |      |

| |Program approved PPI’s: |

| |      |

| |When to abort the PPI: |

| |      |

| | |

| |PPI release criteria: |

| |      |

|VIII. Recovery strategies |

| | |

| |      |

| | |

| | |

|IX. Assessment summary of recommendations/revisions: |

| |

| |      |

| | |

| | |

| |

|X. Author: |      |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download